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Archive for the ‘temporal augmentation’ Category

Temporal Anatomy – Implications for Injection and Temporal Implant Augmentation Methods

Thursday, August 17th, 2017


Temporal hollowing has become a target for aesthetic treatments with the expansion of injection therapies. Injectable fillers and fat injections are the most common temporal augmentation methods. The ease of their use as non-surgical and minimally invasive treatments makes them very appealing to patients and doctors alike. However the temporal region is one of the least satisfying facial areas for injection from an aesthetic standpoint due to unpredictable volume retentions and evenness of the result. In addition, although rare, complications such as blindness and cerebral emboli have been reported. Understanding the anatomy of the temporal would help provide safe guidelines for injectors.

In the September 2017 issue of the Aesthetic Surgery Journal, an article was published entitled ‘Anatomical Study of Temporal Fat Compartments and its Clinical Application for Temporal Fat Grafting’. In this beautifully illustrated cadaveric study, the authors dissected both sides of the temporal regions in eight cadavers looking at its neurovascular and fat compartment anatomy. Their specific intent was to understand the anatomy for the purposes of safe injectable fat grafting. In the subcutaneous layer two fat compartments were identified as a lateral temporal cheek and lateral orbital compartments. In the deeper loose areolar tissue upper and lower temporal fat compartments were found. The anterior branch of the superficial temporal artery and the frontal branch of the facial nerve are located in the superficial temporal fascia. The nerve runs parallel with the artery. The sentinel vein has a vertical orientation and runs just behind the lateral orbital rim through the superficial and deep temporal fascia to drain into the middle temporal vein deep into the muscle.

Based on these studies, the authors conclude that all four fat compartments above the deep temporal fascia are good sites for injection augmentation, particularly fat grafting. Because of the location of the upward course of the neurovascular structures, injecting at at or behind the front edge of the temporal hairline is safe. It is most safe when done in the upper half of this temporal region. Because of the location of the sentinel vein and the frontal branch of the facial nerve, the front half of the lower temporal compartment should be approached with caution or avoided completely.

While this study was done for the purposes of augmentation done above the deep temporal fascia, it validates the safety of temporal implants…the only method of assured permanent temporal augmentation that also creates a smooth out contour. Since temporal implants are placed under the deep temporal fascia, they avoid all neurovascular structures and have no risks of many of the potential injectable temporal augmentation problems. Surgical access is done behind the front edge of the temporal hairline, a safe zone substantiated by this anatomic study. Only the anterior branch of the superficial temporal artery and the auriculotemporal nerve are in this area, both structures which are easily avoided or can be transected without any adverse sequelae.

Dr. Barry Eppley

Indianapolis, Indiana

The Anatomy of Temporal Implant Augmentation

Sunday, June 30th, 2013


Augmentation of the temporal region is a new area for synthetic facial implants. While every other facial implant designed is for bony augmentation, temporal implants provide enhancement of the soft tissue (muscle) region of the side of the forehead and eye.  While injectable filler and fat provide a less invasive approach, they do not offer the capability of producing a one-time permanent solution to temporal hollowing.

The concept of a temporal implant comes from the historic repair of zygomatic arch fractures. Known as a Gille’s approach, depressed arch fractures are elevated from an incision in the hair-bearing temporal region and approached in a subfascial manner down to the bone. The path of dissection is on top of the muscle but under the fascia. It can be seen with the instrumentation that the entire temporal contour can be elevated from below. Thus it was logical to assume that an implant placed in the same location staying above the zygomatic arch would have an augmentative effect. The overlying temporal fascia seems flexible enough and the underlying temporalis muscle stout enough that the implant can push outward rather than inward.

The subfascial plane for a temporal implant is an easy one to surgically approach. And introducing the implant is equally easy. But one question that often comes up is what is to keep the implant from sliding down along the temporalis muscle, below the zygomatic arch and into the lower face? Not only has it never occurred but there are multiple anatomic reasons as to why that can not happen.

The first reason temporal implants have pocket stability is the anatomy of the subzygomatic arch space. While the bony arch does create a space or hole beneath it, the actual dimensions of the created space are less than the width of a temporal implant. As the zygomatic arch curves inward to attach to the temporal bone, it narrows the subzygomatic arch space. Thus when looking from above it can be seen that the front to back length of this space is shorter than the anteroposterior length of a temporal implant.

The second bony reason is the location of the coronoid process of the mandible. The tip of the coronoid process acts as an inferior stop as it juts upward into the subzygomatic arch space. In addition,  onto the coronoid process are the funneled attachments of the temporalis muscle which also creates a soft tissue block.

For these anatomic reasons the temporal implant is prohibited from falling downward into an unintended anatomic location. The surgeon should feel comfortable making a pocket that is felt to be best for implant placement without this concern.

Dr. Barry Eppley

Indianapolis, Indiana

Postoperative Instructions for Temporal Implants

Thursday, February 7th, 2013


Temporal augmentation with implants is done by inserting them through a small vertical incision in the temporal hairline. They are placed on top of the muscle but below the overlying fascia. They are composed of a very soft and flexible silicone material that feels like soft tissue (muscle or fat) and not hard like bone. Different shapes and thicknesses of implants are available to best fill out esch patient’s temporal defects.

The following postoperative instructions for temporal implants are as follows:

1.  Most temporal implant procedures have no discomfort. Patients usually only feel the need to use Tylenol or Ibuprofen for just a few days after the procedure, if any medication at all. You may also feel free to use ice packs on the temples for discomfort relief and swelling reduction the first night after surgery if you desire.

2. In all cases of temporal implants, there will be a circumferential wrap around the head for the first night after surgery. You may remove this wrap the day after surgery. It does not need to be used thereafter.

3. The sutures used in the incision in the temporal hairline will be dissolveable. There is NO need to apply antibiotic ointment on them. They require no topical care.

4. You may shower as normal the following day and you may wash your hair as normal 48 hours after surgery. There is no harm in getting the temporal suture lines wet.

5. Temporal implants may cause some swelling and bruising the eyelids or cheeks in some patients. You may was your face and apply make-up over any bruised areas the following day.

6. There are no limitations to any physical activities after temporal implant surgery. You may feel free to run, workout and do any non-contact sporting activity as soon as you feel comfortable.

7. You may eat and drink whatever you like right after surgery.

8.  You may drive the next day after surgery when you feel comfortable and are not on any pain medication.

9.  You may wear regular or sunglasses when the temporal swelling permits and it feels comfortable to do so.

10. If any temporal redness, increased tenderness or swelling, or incisional drainage develops after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.

Implants for Temporal Augmentation

Friday, February 1st, 2013


There are a large number of available implants that seemingly provide aesthetic augmentation for every conceivable facial location. Most facial implants are made of a soft flexible silicone elastomer material whose physical properties allow them to be relatively easy to surgically place and remove if necessary. Also, a silicone elastomer material allows for any size and shape of a facial implant to be made at an economical cost.

While most sites of facial implant augmentation are done to augment skeletal convexities and concavities, facial soft tissue augmentations can be desired as well. One such soft tissue area is that of temples. The aesthetic boundaries of the temples is bounded by four sides, the anterior temporal hairline, the top part of the zygomatic arch, the lateral wall of the orbit and a small portion of the lateral forehead. The contour of the temples is either flat or slightly concave. This contour is controlled by the thickness of the underlying temporalis muscle and fat pad and not by the temporal skull bone as if often thought.

When the temples are excessively concave (sunken in), treatment is often sought for augmentation. Most temporal augmentations are done by injections of either synthetic materials (IJuvederm, Radiesse, Sculptra) or fat. While an injectable temporal augmentation approach can be effective, they often have to be repeated for maintenance of the augmentative effect. Fat injections can also be unpredictable in terms of volume survival and may also have to be repeated to create a more pronounced and/or more prolonged effect.

For a permanent effect, a new silicone implant is now available for aesthetic temporal augmentation. (Temporal Shell Implant, Implantech, Ventura, CA) Composed of a very soft and low durometer silicone material, it feels very similar to muscle or fat tissue. Its shape matches the typical borders of the temporal region. It is thicker at its bottom portion where more augmentation is needed and has upper feathered edges to blend into the upper temporal area without visible edge demarcation. As a soft tissue implant, it should be placed under the temporalis fascia on top of the temporalis muscle through a small vertical incision in the temporal hairline. While it can be placed on top of the temporalis fascia, there are increased risks of implant visibility and injury to the frontal branch of the facial nerve.

Temporal Shell implants are currently available in two sizes. The implants have radiating lines on them, not only for flexibility, but also for implant shaping if needed. Scissors can be used to quickly shape and customize the implant for any patient’s temporal dimensional needs.

Temporal implant augmentation is very straightforward and could be even be done under local or sedation anesthesia. Subfascial pocket dissection is rapid and risks no injury to any blood vessel or nerves. There is very little swelling and usually no bruising after the procedure. Patients report no pain afterwards.There are no physical restrictions or care needed after surgery.

Temporal Shell Implants are now available to provide permanent soft tissue augmentation for aesthetic concave deformities of the temporal region. They can be used when either an injectable temporal augmentation has failed or a more assured one-time permanent effect is desired. The implants are uniquely made to create a soft tissue effect rather than a more firm bony augmentation commonly used for facial skeletal augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery’s Did You Know? Temporal Beauty

Tuesday, July 24th, 2012


One of the last facial areas to be cosmetically enhanced is that of the temples. Not to be confused with places of worship and even having slightly different Latin word derivations, the temples anatomically are to the side of the eye along the side of the head. Aesthetically, it is a near isosceles triangle with the lower horizontal border of the zygomatic arch, the anterior border of the lateral orbital wall and the angulated posterior border of the temporal hairline. It usually has a very slight depression if a plumb line is laid across any of its borders. Temporal hollowing is judged to occur when the depression becomes greater than a few millimeters. Temporal bulging, which is much more rare, is when the underlying muscle pushes out  the skin beyond the projection of its borders. Temporal hollowing can occur because of genetics, extreme weight loss, medications and certain diseases, all creating resorption of the temporal fat pad. Temporal hollowing is treated today by injectible synthetic fillers and fat grafts and a variety of performed synthetic implants and allogeneic materials placed through a small incision in the temporal hairline.  

Temporal Augmentation with Fat Injections

Sunday, March 4th, 2012

A recent news story out of the UK in London headlined the transfer of fat from a man’s stomach to his head to reshape it. Given that fat injections to the face, breast and buttocks have become so popular over the past decade, such a story is at the very least noteworthy.

The patient was a young 32 year-old man had some of his skull removed and surgery to reconstruct a shattered eye socket, cheekbone, and leg, following injuries sustained when he fell while climbing up a drainpipe outside his house. To ease brain swelling caused by his fall, a piece of his skull was initially removed which is standard practice in these type of injuries. Also he had titanium plates inserted to fix his broken eye socket and hold the bones together.Six months after his initial injury, the missing piece of his skull was reconstructedwith a computer-generated titanium plate based on the shape of his opposite normal skull. Despite restoring the bony shape of the skull, his temple area still remain indented. This is common after such skull procedures as the temporalis muscle, which needs to be raised off of the bone to perform the procedure, will shrink down in size during the healing process.

This ‘temporalis muscle atrophy after a craniotomy’ is well known and has been treated over the years by many methods. In this patient’s case, the surgeons used stomach fat harvested by ljposuction which was then injected into the temporal skull defect to fill it out for a smoother contour. How well the fat survived and adequately reconstructed the temporal defect months later was not described in the news story.

Reconstruction of a cosmetic temporal defect can be done with either a synthetic implant, allogeneic tissue grafts or fat injections. There are advantages and disadvantages to any of these approaches. Fat injections, just like they do for every other face and body application, offers a minimally-invasive procedure with a cannula harvest and a needle injection technique. Its disadvantage is in how much of the injected fat will survive. Experiences with temporal fat injections vary widely with some reporting good volume retention and others near complete absorption. I have seen both outcomes in my temporal augmentation with fat. For assured temporal augmentation results, a simple insertion of a specially-designed silicone temporal implant provides a permanent solution.

Dr. Barry Eppley

Indianapolis, Indiana

A New Shaped Implant for the Treatment of Temporal Hollowing

Saturday, July 2nd, 2011

The temporal region of the face, technically the side of the head, occupies an often overlooked aesthetic area. It is bounded superiorly by the anterior temporal line of the forehead, anteriorly by the lateral edge of the bony brow and eye socket, inferiorly by the zygomatic arch and posteriorly by an indistinct margin in the temporal scalp hair. It is not a bony-supported region by rather one of soft tissue, the temporalis muscle and the deep fat pad. The temporalis fascia  covers the muscle and acts like a taut trampoline attached to the surrounding bony edges.

The aesthetic shape of the temple is determined by whether it has a convex, flat or concave appearance. There is no uniform standard or anthropometric measurement to judge what is its ideal shape. A flat or slightly concave temple area appears most common. A bulging or overlying convex appearance is unusual and unappealing and is rarely seen. An overlying concave appearance suggests a sickly or ill appearance. The shape and prominence of the forehead also influences how concave the temporal region will appear.

The most common aesthetic deformity of the temporal region is excessive concavity or depression. It can be caused from surgery (temporalis muscle wasting after a craniotomy), a medical condition (fat atrophy from extreme weight loss or medications) or one’s natural genetics. (congenital lipoatrophy) Regardless of its etiology, some form of an implanted material is needed to build out the temporal depression.

Methods for temporal augmentation have included injected fat, dermal grafts, bone cements or cranioplasty materials and various synthetic implants. Each has their own advantages and disadvantages and have different locations of placement, either above the fascia, below the fascia, intramuscular or on top of the temporal bone. Depending upon the cause for the temporal deformity, there may be benefits to one method of augmentation over the other.

While differing synthetic materials have been used, there has not been few if any preformed temporal implants available. A new preformed temporal implant is now available made out of flexible silicone rubber. Its shape mirrors the natural contours of the inferomedial bony boundaries where the greatest temporal concavity occurs. Its beveled shape allows differential augmentation to be achieved in an anteroposterior dimension so the augmentation is not too excessive near the hairline. Two different sizes are currently available.

Besides the innate flexibility of silicone, the implant is also designed with cross-cut ridges of material underneath to allow even greater three-dimensional implant adaptability. This could be a useful feature to allow the implant to not impede the excursion of the temporalis muscle with mastication.

In aesthetic augmentation, a temporal implant is best placed in the subfascial plane. This is easily done by a small vertical incision in the temporal hairline. This location allows the implant to be placed in a position that maximizes its shaped design. The curved form of this new temporal implant allows it to be rotated in through an incision that is smaller than its widest part. It can also be placed above the fascia but this places the frontal branch of the facial nerve at risk.

In augmentation of temporal defects from craniotomies, the temporalis muscle may be very scarred or severely atrophied. Placing it under the temporalis muscle in these craniotomy-induced defects may be preferable.

This new implant offers another treatment option for temporal hollowing. Its unique shape, flexibility and well-established tolerance to the material is a welcome addition to the expanding number of available cranial and facial implants.

Dr. Barry Eppley

Indianapolis, Indiana

Dermal Graft Temporal Augmentation

Tuesday, October 5th, 2010

The temple is a small and often unappreciated region of the face. The most visible part of the temporal region is situated between the side of the eye and the hairline behind it. It is vertically bounded by where it becomes part of the forehead (anterior temporal line) and the zygomatic arch below. (back part of cheek bone where it extends back to in front of the ear) It is primarily made up of the bulk of the temporalis muscle and its underlying fat pad. Normally, it is relatively flat not being too full or indented.

Cosmetic temporal changes do occur and they appear primarily as temporal hollowing or indentations. Too much temporal fullness can occur from overdevelopment of the muscle but this is quite rare. Temporal hollowing can occur from either muscle or fat atrophy. Disruption of the deep and middle temporal arteries is recognized as causing this ischemia. Well known causes are after surgical exposure of the area (neurosurgery or craniofacial surgery), radiation for intracranial malignancies, and traumatic injury. The other recognized causes of temporal hollowing are fat wasting due to automimmune diseases, retroviral medication, and malnutrition. But there is also a cosmetic temporal hollowing that has no obvious causes other than underdevelopment of temporal fullness, what I call congenital temporal hollowing. (CTH) There are some craniofacial syndromes where this occurs but it also appears merely as a cosmetic deformity.

In cosmetic CTH, there is an obvious indentation that is about the size of one’s thumbprint just to the side of the eye. (lateral orbital rim) It is not the size of what one would see from larger temporal hollowing from well recognized causes. But it creates a very visible cosmetic indentation that gives an hourglass shape to the side of the face. Correction of this form of temporal hollowing can be done by variation of traditional temporal augmentation procedures.

Traditional temporal augmentation procedures require extended scalp incisions and the use of some type of hard and soft tissue synthetic implant materials. But the smaller size of cosmetic temporal indentations do not justify these more invasive procedures. A minimally-invasive temporal augmentation procedure can be done that is both simple and very effective.

This limited temporal augmentation procedure uses a small 2.5 cm incision located just behind the temporal hairline at the level of the indentation. The incision ends up just below the frontal branch of the superficial temporal artery which is seen just above it during the dissection. The deep temporal fascia is incised and dissection is done in a subfascial plane underneath the indentation out to the lateral orbital rim. This dissection is below the level of the frontal branch of the facial nerve, which is in the more superficial temporalis fascia, so there is no risk of temporary or permanent forehead paralysis. This dissection is easy, quick, and could even be done under local or IV sedation anesthesia.

The critical question is what implant material to use. Since the material placement is on top of the temporalis muscle, just about any graft material would work including the full range of synthetic options.  But the use of a more natural or collagen-based material is appealing and the recipient site is ideal. I prefer the use of allogeneic human dermis of which many tissue bank providers exist. (e.g. Alloderm, Dermacell) With thicknesses of 1 to 1 ½ millimeters, it can be layered for increased thickness and cut to any shape. It is easily inserted in a flat or rolled configuration. Enough graft is placed to just slightly overbuilt it. The incision is closed with tiny dissolveable sutures. No dressings are used.

The results of the dermal graft temporal augmentationprocedure are immediate and very satisfying. There is no wound care needed with the incision in the hairline. One can shower and wash their hair the next day. There will be some mild swelling and occasionally a little bruising if the fascia attachments along the lateral orbital rim need to be released to get a smooth contour. With dermal grafts, the final volume outcome should await the six month after surgery time period. But their placement in muscle bodes well for long-term volume retention.   

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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